Fillable Eligibility Form Initial Tier 3 licensure (Minnesota)

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Eligibility Form Initial Tier 3 licensure (Minnesota)

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  • 6 check-boxes
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File type: PDF

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Eligibility Form-Initial 12_2020 Page 1 of 3
Eligibility Form
Licensure via Portfolio Evaluation Application for:
Initial Tier 3 licensure
THIS FORM IS VALID FOR ONE YEAR. *PLEASE SEE INFORMATION ON PAGE 3
Send the following information: (1) this Eligibility form; (2) a copy of your regionally
accredited college transcripts; (3) a written description of your teaching or related
experiences; and (4) your resume to the Minnesota Professional Educator Licensing and
Standards Board.
Do you hav
e a Minnesota License File Folder Number? Yes No
If yes, enter your File Folder Number ____________
Name: __________________________________________________ Date: _________________________
Address: ___________________________________ City: _________________ State: ____ ZIP: ________
Home Phone: ______________ Alternate Phone: _______________ Email: _________________________
Education
Degree: _______ Major(s):____ Institution: _______________________________________ _______________________
Degree: _______ Major(s):___________________________Institution: _______________________________________
Degree: _______ Major(s):___________________________Institution: _______________________________________
Teaching Experience or Mentorship is Required – see page 2
Portfolio Application Submitted for (check all that apply): *Further instructions on page 3
Standards of Effective Practice (pedagogy) Special Education Core Skills
Career and Technical Education Core Skills Subject Matter Standards and Content Specific (list below)
Field: Field:
Field: Field:
_________________________________________ _______________________
Applicant’s Signature Date
For Office Use Only:
Date Info Verified: _______________ Date Emailed: _________________
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Eligibility Form-Initial 12_2020 Page 2 of 3
Name File Folder Number
Verification of Teaching Experience
Complete this section if you are using teaching experience to apply for Licensure via Portfolio.
District/School Name
Location
(city, state)
Dates of
Employment
Percentage
Full Time
Specific
Subject Taught
Grade
Level
Taught
Start End
Name of District or Charter School (Minnesota schools: include six-
digit district number)
Mailing Address (city, state, zip code)
Printed Name of Authorized Official Email Address
Signature of Authorized Official Date Ten-Digit Telephone Number
If this included a year-long mentorship program aligned to board-adopted criteria (see
definition at https://www.revisor.mn.gov/rules/8710.0310/) please attach the completed
signed evaluation and list dates of mentorship: ______________________________.
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Eligibility Form-Initial 12_2020 Page 3 of 3
Eligibility Form
Licensure via Portfolio Evaluation Application Information for
Initial Tier 3 Licensure.
• This form is valid for one year.
• Any individual who has a minimum of a regionally accredited baccalaureate degree (or Career
and Technical Education exception), and one of the following; (1) a year-long mentorship
program aligned to board-adopted criteria; or (2) two years of experience teaching as the
teacher of record in the licensure area sought, may be able to use the licensure via portfolio
process as an alternative pathway to a tier 3 license.
• Initial licensure requires a content portfolio and a standards of effective practice (pedagogy)
portfolio. *Depending on content field, this may also include a core portfolio as indicated below.
• All testing must be completed before license is issued.
• Portfolio review fee is non-refundable.
Form and documentation can be emailed to: portfolio.pelsb@state.mn.us, or mailed to:
Licensure via Portfolio-PELSB
1021 Bandana Blvd E Suite 222
St. Paul, MN 55108
*Content Standard Grids for Educator Licenses via Portfolio
Standards of Effective Practice Grid
A Standards of Effective Practice (pedagogy) portfolio is a requirement for a tier 3 license.
Core Skills for Teachers of Career and Technical Education Grid
A Core Skills for Teachers of Career and Technical Education portfolio is required for an initial tier
3/tier 4 license in the Career and Technology Education fields such as; Communication Technology
Careers, Construction Careers, Manufacturing Careers, Medical Careers, Creative Design Careers,
Early Childhood Careers, Hospitality Service Careers, and Transportation Careers.
Core Skills for Teachers of Special Education Grid
A Core Skills for Teachers of Special Education portfolio is required for an initial tier 3/tier 4 license in
the Special Education fields such as; Academic and Behavioral Strategist, Blind or Visually Impaired,
Deaf or Hard of Hearing, Oral/Aural Deaf Education, Developmental Adapted Physical Education,
Developmental Disabilities, Early Childhood Special Education, Emotional or Behavioral Disorders,
Learning Disabilities, Physical and Health Disabilities, and Autism Spectrum Disorders.
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Eligibility Form Initial Tier 3 licensure (Minnesota)

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Completed 1 March 2021

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